组态视角下医保欺诈形成路径及防范策略研究  

Research on the Formation Path and Prevention Strategies of Medical Insurance Fraud from the Perspective of Configuration

作　　者：毛茜 李春波 詹长春[1] 周绿林[1] Mao Qian;Li Chunbo;Zhan Changchun;Zhou Lülin(School of Management,Jiangsu University,Zhenjiang,Jiangsu,212013,China;School of Business,Nanjing University,Nanjing,Jiangsu,201093,China;不详)

机构地区：[1]江苏大学管理学院,江苏镇江212013 [2]南京大学商学院,江苏南京201093

出　　处：《中国卫生经济》2025年第3期37-42,共6页Chinese Health Economics

基　　金：国家自然科学基金项目(72104092);江苏大学大学生科研立项项目(22C227)。

摘　　要：目的:探索导致医保欺诈形成的机制,以期为防范医保欺诈提出对策建议。方法:以我国30个省份为研究对象,运用模糊集定性比较分析法和必要条件分析法探讨导致医保欺诈的组态路径。结果:单个要素并不构成医保欺诈高发的必要条件;导致医保欺诈高发的组态路径有4条,分别是医保运行状况不佳主导型、医保运行状况不佳主导下低信息化水平—弱监管机制双因素辅助型、医保运行状况不佳—低信息化水平双因素主导下低经济水平辅助型、医保运行状况不佳—弱监管机制—低经济水平三因素主导型。结论:医保欺诈是多因素共同导致的,因此提出以下防范策略,即以重点整治突破难点问题、以部门联动强化监管成效、以技术赋能提升监管精度、以标本兼治健全长效机制。Objective:To explore the mechanism that leads to the formation of medical insurance fraud,in order to propose countermeasures and suggestions for preventing medical insurance fraud.Methods:Taking 30 provinces and cities in China as research objects,Fuzzy-Set Qualitative Comparative Analysis and Necessary Condition Analysis are applied to explore the configuration paths that lead to medical insurance fraud.Results:A single factor does not constitute a necessary condition for a high incidence of Medicare insurance fraud.There are four grouping paths that lead to a high incidence of Medicare insurance fraud,namely,the dominant factor of poor medical insurance operation status,the dual auxiliary factor of low informationization level and weak regulatory mechanism under the dominant status of poor medical insurance operation,the auxiliary pathway of low economic level under the dual dominance factors of poor medical insurance operation and low informationization level,and the three dominant factors of poor medical insurance operation as well as weak regulatory mechanism and low economic level.Conclusion:Medical insurance fraud is caused by multiple factors,therefore the following prevention strategies are proposed,focusing on rectifying and breaking through difficult problems,strengthening regulatory effectiveness through departmental linkage,enhancing regulatory accuracy through technological empowerment,and improving long-term mechanisms by addressing both symptoms and root causes.

关 键 词：社会医疗保险 医保欺诈 防范策略 模糊集定性比较分析法 必要条件分析法 

分 类 号：R1-9[医药卫生—公共卫生与预防医学] F840.684[经济管理—保险]